The thinking behind placement of tissue expanders for postmastectomy breast reconstruction has come full circle, says Gedge Rosson, director of breast reconstruction.

“In the ‘70s and ‘80s, plastic surgeons were putting reconstructions just under the skin, above the pectoralis muscle, which seems the logical place because that’s where the breast tissue is,” he says. “But they had tons of problems: the implants weren’t good, the mastectomy skin would be thin and then get radiated, exposing the implant. It wasn’t a very consistent way to do reconstruction.” As a result, surgeons gradually switched to putting expanders under the pectoralis muscle and dramatically improved their outcomes.

But with the advent of better implants and scaffolding products to support the expanders—such as acellular dermal matrix (ADM), a skinlike material that serves as a placeholder between mastectomy and reconstruction and fat grafting—Rosson and colleagues have reverted to placing the expanders above the pectoralis, with the goal of improving aesthetic results and reducing patients’ pain because the muscle doesn’t need to be cut and stretched. Through a prospective clinical trial, Rosson is tracking results among mastectomy patients given tissue expanders reinforced by ADM, looking for outcomes such as postoperative pain and cosmetic results as well as factors such as nausea, quality of life and hospital length of stay.

An early retrospective review of the first 26 patients treated this way, accepted for publication, indicated that patients’ pain scores were two points lower on a standardized 10-point pain scale—a statistically significant difference—over 109 patients treated with the older technique.

In another study, a randomized controlled trial, Rosson and colleagues are evaluating whether injecting bilateral mastectomy patients with an anesthetic drug in the area of the thoracic spinal nerves before surgery (a preoperative paravertebral block) will decrease postoperative pain and improve long-term quality of life.

“We’re very concerned about postmastectomy pain syndrome—chronic pain after mastectomy,” which can affect a reported 2 percent to 20 percent of women, says Charalampos “Harry” Siotos, a clinical research fellow in the department. During the trial, women will be randomized to receive either the anesthetic ropivacaine or a placebo before surgery; researchers will measure the women’s postoperative pain up to a week after surgery and their quality of life through questionnaires up to four years after the procedure.

While the team may enroll as many as 70 patients for the study, funded by the Plastic Surgery Foundation, they will do an intermediate analysis on results from the first 25 participants, Siotos says. If the drug is shown to be beneficial, they’ll stop the trial and begin offering the treatment regularly.